The Joint Commission
ECNews
July 2013
Environment of Care
Emergency Management
Volume 16
Issue 7
Life Safety
Labeling the Hazard
OSHA to institute “global harmonization” of hazard communications
H
azardous chemical labels will soon have a new
look—and workers will need to be trained to
recognize it.
Beginning shortly, OSHA will require that hazardous chemical containers be labeled with a whole new set of standardized
pictograms (see Figure 1, p. 3). The easily identified symbols will
be the same around the world. Having the symbols “globally
harmonized” will help workers in countries around the planet
recognize exactly what type of hazardous material is in a container, regardless of what country it was shipped from and what
language it’s in.
The new hazardous chemicals labeling requirements are part
of OSHA’s recent revision of the Hazard Communication Standard (HCS), 29 CFR 1910.1200, bringing it into alignment
with the United Nations’ Globally Harmonized System of
Classification and Labelling of Chemicals (GHS).
The revised OSHA standard requires that information about
chemical hazards be conveyed on labels using quick visual notations to alert the user and provide immediate recognition of the
hazards. The label provides information to the workers on the
specific hazardous chemical. Labels must also provide instructions on how to handle the chemical so that chemical users are
informed about how to protect themselves. Specifically, labels
must contain the following information: product identifier; signal word; hazard statement(s); precautionary statement(s); pictogram(s); and the name, address, and telephone number of the
(continued on page 3)
Under OSHA’s recent revision of the Hazard Communications Standard (29 CFR 1910.1200), the symbols and frames
presented above will no longer be acceptable as of June 1,
2015. Harmonized pictograms (shown in Figure 1) will
replace such symbols on hazardous chemical labels.
Inside
2
Test Your Standards IQ
5
Clarifications and Expectations: Ensuring Full
Compliance with the Life Safety Code®
Tips on meeting recurring compliance issues
7
OSHA & Worker Safety: Protection Partnership
How health care organizations can better secure the safety of
workers and patients alike
10 Revisions to Applicability of EC Requirements
for Freestanding Ambulatory Infusion and
Rehabilitation Technology Settings in the
Home Care Program
Executive Editor: Kristine M. Miller, MFA
Senior Project Manager: Cheryl Firestone
Manager: Lisa Abel
Executive Director: Catherine Chopp Hinckley, PhD
Contributing Writers: Kathleen Vega, Erik Martin
Test your
STANDARDS
Technical Support and Review:
Standards Interpretation Group
Patricia Adamski, RN, MS, MBA, Director
IQ
Department of Engineering
George Mills, MBA, FASHE, CEM, CHFM,
CHSP, Director
Anne M. Guglielmo, CFPS, CHSP, LEED AP,
Engineer
John D. Maurer, CHFM, CHSP, Engineer
Department of Standards and Survey Methods
John Fishbeck, RA, Associate Director
Editorial Advisory Board:
David A. Dagenais, CHSP, CHFM, SASHE,
Wentworth Douglass Hospital, Dover, NH
Katherine Grimm, MPH, Emergency Management
Coordinator, Maple Grove Hospital,
Maple Grove, MN
David P. Klein, PE, Department of Veterans Affairs,
Washington, DC
Michael Kuechenmeister, FASHE, CHFM, CPE,
West Chester Medical Center, Cincinnati
William R. (Bill) Morgan, SASHE, CHFM,
St. Alphonsus Regional Medical Center, Boise, ID
George A. (Skip) Smith, CHFM, SASHE,
Catholic Health Initiatives, Denver
Jen Carlson Steinmetz, MPH, MBA,
Manager, Occupational Health and Safety,
Northwestern Memorial Hospital, Chicago
Subscription Information:
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Orders for 20–50 single/back issues receive a 20%
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orders to Joint Commission Resources, 16442
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more information, call 800-746-6578. Environment of
Care® News (ISSN 1097-9913) is published monthly
by Joint Commission Resources, 1515 West 22nd
Street, Suite 1300W, Oak Brook, IL 60523.
© 2013 The Joint Commission
No part of this publication may be reproduced or
transmitted in any form or by any means without
written permission.
Joint Commission Resources, Inc. (JCR), a not-forprofit affiliate of The Joint Commission, has been
designated by The Joint Commission to publish
publications and multimedia products. JCR reproduces and distributes these materials under license
from The Joint Commission.
E-mail us at [email protected] with your article
ideas. Visit us on the Web at http://www.jcrinc.com.
To contact the Standards Interpretation Group with
standards questions, phone 630-792-5900.
The Questions
Time to get sharp on The Joint Commission EC standards and essential
information. Use this feature to beef up your knowledge, as a quick reminder of
what you already know, or to help educate your staff on a variety of EC, EM, and
LS standards and information. You’ll find the answers (if you don’t already know
them) on page 11. Okay, ready?
1. How frequently must a laboratory monitor hazardous gas and
vapor levels?
a. Daily
b. Monthly
c. Yearly
d. At a frequency determined by law and regulation
2. Egress doors in all hospitals must swing in the direction of
egress.
True or False?
3. After granting disaster privileges to a volunteer licensed
independent practitioner, within what time frame must a
hospital determine whether the practitioner’s disaster
privileges should continue?
a. 24 hours
b. 48 hours
c. 72 hours
d. A week
4. Only hospitals and critical access hospitals must map their
utility systems.
True or False?
5. How frequently must an ambulatory care organization test any
visual and audible fire alarms present in the facility (including
speakers)?
a. Once a month
b. Once a quarter
c. Every 6 months
d. Every 12 months
How did you do? Check the answer key on page 11.
2
EC NEWS
July 2013
www.jcrinc.com
Labeling the Hazard
(continued from page 1)
Figure 1. Labels and Pictograms
What to Look for on a Label
• Name, address, and telephone
number
• Product identifier
• Signal word
• Hazard statement(s)
• Precautionary statement(s)
• Pictogram(s)
chemical manufacturer, importer, or
other responsible party (see the box
above and Figure 2, below).
Safety data sheets
In addition, safety data sheets (SDS—
formerly referred to as “material safety
data sheets,” or MSDS) will also have a
new standardized look that will help
workers anywhere quickly find and
understand the information they need.
The revised standard requires the use of a
16-section SDS format, which provides
detailed information regarding the chemical. As with MSDS, OSHA requires that
OSHA will enforce the use of eight of these pictograms on hazardous chemicals.
The environmental pictogram is not mandatory but may be used to provide
additional information.
(continued on page 4)
Figure 2. Hazard Communication Standard Labels
This label contains
all the elements
the new OSHA
regulations
require. You can
use this Quick
Card™ to train
employees about
the new labels.
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EC NEWS
July 2013 3
Labeling the Hazard
(continued from page 3)
SDS be kept in work areas where chemicals are used and stored. Labels provide
important information for anyone who
handles, uses, stores, and transports hazardous chemicals, but, of course, they are
limited by design in the amount of
information they can provide. SDS are a
more complete resource for details
regarding hazardous chemicals.
Training
Although the deadline for updating the
labels is June 1, 2015,* the deadline for
training workers is much sooner:
December 1, 2013. Organizations will
want to get their training programs up
and running quickly, and OSHA has
provided training tools including briefs
and “Quick Card™” visuals to help
do that. You can find them at
http://www.osha.gov/dsg/hazcom. A
sample Quick Card™ is shown in Figure
2. The box at right contains the minimum required topics for the training that
must be completed by December 1,
2013.
Joint Commission
requirements
The Joint Commission’s standard
EC.02.01.01 and related elements of
performance (EPs) require that accredited organizations manage “risks related
to hazardous materials and waste.”
Specifically, EC.02.01.01, EP 11,
requires organizations to have the “safety
data sheets required by law,” and
EC.02.01.01, EP 12, requires organizations to label “hazardous materials and
waste. The labels identify the contents
and hazard warnings.” EC
* Distributors may continue to ship containers
labeled by manufacturers or importers (but not by
the distributors themselves) in compliance with
HazCom 1994 until December 1, 2015.
4
EC NEWS
July 2013
Hazard Communications Training Topics
This list contains the minimum required topics for the training that must be
completed by December 1, 2013, according to OSHA.
Training on label elements must include information on the following:
• The type of information the employee would expect to see on the new labels,
including the following:
✓ Product identifier: how the hazardous chemical is identified. This can be (but is
not limited to) the chemical name, code number, or batch number.
✓ Signal word: used to indicate the relative level of severity of hazard and alert
the reader to a potential hazard on the label. There are only two signal words,
“Danger” and “Warning.” Within a specific hazard class, “Danger” is used for
more severe hazards, and “Warning” is used for less severe hazards.
✓ Pictogram: OSHA has designated eight pictograms under this standard for
application to a hazard category.
✓ Hazard statement: describes the nature of the hazard(s) of a chemical,
including, where appropriate, the degree of hazard. For example: “Causes
damage to kidneys through prolonged or repeated exposure when absorbed
through the skin.”
✓ Precautionary statement: means a phrase that describes recommended
measures that should be taken to minimize or prevent adverse effects
resulting from exposure to a hazardous chemical or improper storage or
handling.
✓ Name, address, and phone number of the chemical manufacturer, distributor,
or importer
• How an employee might use the labels in the workplace, including the
following examples:
✓ Explain how information on the label can be used to ensure proper storage of
hazardous chemicals.
✓ Explain how the information on the label might be used to quickly locate
information on first aid when needed by employees or emergency personnel.
• General understanding of how the elements work together on a label,
including the following examples:
✓ Explain that where a chemical has multiple hazards, different pictograms are
used to identify the various hazards. The employee should expect to see the
appropriate pictogram for the corresponding hazard class.
✓ Explain that when there are similar precautionary statements, the one that
provides the most protective information will be included on the label
Training on the format of the safety data sheets (SDS) must include
information on the following:
• Standardized 16-section format, including the type of information found in
the various sections
• How the information on the label is related to the SDS
This article was developed through the
cooperative efforts of the OSHA/Joint
Commission Resources Alliance.
www.jcrinc.com
a
n
d
Clarifications Expectations
WITH THE JOINT COMMISSION’S DIRECTOR OF ENGINEERING, GEORGE MILLS
Ensuring Full Compliance with the
Life Safety Code®
Tips on meeting recurring compliance issues
The Joint Commission has identified the
need to increase the field’s awareness and
understanding of the Life Safety Code®*
as well as other key environment of care
concepts. To address this need, Environment of Care® News publishes the column
Clarifications and Expectations, authored
by George Mills, MBA, FASHE, CEM,
CHFM, CHSP, director, Department of
Engineering, The Joint Commission. This
column clarifies standards expectations and
provides strategies for challenging compliance issues, primarily in life safety and the
environment of care but also in the vital
area of emergency management. You may
wish to share the ideas and strategies in this
column with your organization’s leadership.
S
ince 1968, The Joint Commission
has required accredited organizations to comply with the National
Fire Protection Association’s Life Safety
Code®. To help organizations with compliance efforts, The Joint Commission
created the “Life Safety” (LS) chapter of
the Comprehensive Accreditation Manual.
This chapter supports an organization’s
efforts to be fully compliant with the
code.
Because of the size and scope of the
Life Safety Code, the LS chapter does not
fully delineate every NFPA requirement.
* Life Safety Code® is a registered trademark of the
National Fire Protection Association, Quincy, MA.
† Boldface added for emphasis.
‡ Unless otherwise noted, all NFPA code references are taken from NFPA 101-2000.
www.jcrinc.com
However, it has always been the Joint
Commission’s intention that health care
organizations comply with the complete
set of NFPA requirements in The Life
Safety Code.
To clearly communicate this intent,
The Joint Commission includes several
standards in the LS chapter that relate to
the topic of full compliance. For example, in Standard LS.02.01.20, which
deals with means of egress requirements,
element of performance (EP) 32 states
that “the organization meets all other†
Life Safety Code means of egress requirements related to NFPA 101-2000,
18/19.2.” So, if during survey, an organization is found to be noncompliant with
one of the means of egress requirements
not specifically addressed in EPs 1–31, a
surveyor would score that noncompliance at EP 32.
Recently, The Joint Commission has
noticed some recurring compliance issues
that are scored at EP 32 and similar “full
compliance” EPs in the LS chapter.
These EPs include, but are not limited
to, LS.02.01.20, EP 32; LS.02.01.30, EP
25; and LS.02.01.34, EP 4.
This article looks at some of those
issues, so that organizations can be aware
that these topics may be addressed
during survey.
Means of egress (LS.02.01.20,
EP 32)
A deficiency scored at EP 32 of
LS.02.01.20 may address door width in
means of egress doors and doors from
sleeping rooms and diagnostic and treatment areas, such as x-ray, surgery, physical therapy, and nursery rooms. A
means of egress is a continuous and
unobstructed way of exit travel from any
point in a building or structure to a public way. For existing buildings, the Life
Safety Code requires that these doors not
measure less than 32 inches clear width
(see NFPA 101-2000,‡ 19.2.3.5). Doors
located in these areas in new health care
buildings must have a minimum clear
width of 41.5 inches (see 18.2.3.5). Clear
width—that is, the unobstructed width
of the door opening without projections
into such width—is measured by subtracting the door stops built into the
door frame plus the thickness of the door
itself at the hinge edge from the total
door opening. For example, subtracting
the door stop and hinge stile edge from a
44-inch door leaf would be 41.5 inches
clear width. (Note that prior to 1994, the
Life Safety Code specified door measurements for the door leaf width rather than
the current clear width.)
Smoke barrier doors
(LS.02.01.30, EP 25)
Several issues regarding smoke barrier
doors have been cited at LS. 02.01.30,
EP 25. One deals with the fire rating of
smoke barrier doors. The Life Safety Code
requires that doors found in a smoke
barrier be either of substantial construc(continued on page 6)
EC NEWS
July 2013 5
Ensuring Full Compliance with the Life
Safety Code®
(continued from page 5)
tion (for example, 1.75 inches thick,
solid-bonded wood core) or of construction that resists fire for not less than 20
minutes. Any door that is either not substantial or fails to resist fire for at least 20
minutes is not compliant (see
18/19.3.7.5 and 18/19.3.7.7).
Another code requirement scored at
EP 25 relates to the swing direction of
smoke barrier doors. Under the code, in
existing construction doors are not required to swing in the direction of egress.
Pairs of doors in existing construction
often swing in the same direction, which
is acceptable under the code. However,
in new construction, swinging doors
must be hung so the doors swing in
opposite directions (see 18.3.7.5).
Smoke barrier door width is also
addressed at EP 25. Similar to means of
egress doors, smoke barrier doors in
existing health care occupancies must
measure 32 inches clear width; they must
measure 41.5 inches clear width in new
construction (see 18.3.7.5 and 19.3.7.7).
New construction also requires door edge
treatments, such as rabbets, bevels, or
astragals, at the meeting edges of smoke
barrier doors (see 18.3.7.8). Door edge
treatments are not required in existing
construction.
Fire alarms (LS.02.01.34, EP 4)
To comply with the Life Safety Code
under Standard LS.02.01.34, EP 4, a
fire alarm system must be activated in
one of the following ways:
• Manual fire alarm initiation (that is,
someone pulls the alarm)
• Automatic detection
• Extinguishing system operation
To ensure that the manual fire alarm
pull box is easy to get to, the Life Safety
Code requires that the box be always
accessible, unobstructed, and visible.
6
EC NEWS
July 2013
Accessibility includes travel distance,
with travel distance to the manual fire
alarm pull box not exceeding 200 feet.
The pull station must be located in a
natural exit access path near each exit
from an area, unless located at the nurse’s
station (or other continuously attended
staff location).
Although this requirement may seem
straightforward, an organization may
inadvertently place itself out of compliance. For example, suppose an organization has located the manual fire alarm
pull box in the nursing station rather
than at the unit exit. During a remodeling project, the organization moves the
nursing station but leaves the manual fire
alarm pull box in place, about 100 feet
from an exit. The pull box is no longer
correctly positioned because it is not at
the nursing station and is too far from an
exit. This situation results in noncompliance for the organization (see 18/19.3.4.2
and 9.6.2.1–9.6.2.6).
Automatic sprinkler systems
(LS.02.01.35, EP 14)
If an organization is required to have an
automatic sprinkler system, then it must
have an adequate and reliable water supply to feed the system. Systems that have
fire pumps must be tested to ensure that
there is adequate flow to support the
pumps. Standard EC.02.03.05, EP 11,
addresses this issue, requiring systems
with fire pumps to be tested annually.
Some fire extinguishing systems are
fed directly by a city supply (or other
means that are out of an organization’s
control). These systems might face challenges. If the organization experiences a
reduction in water supply, this becomes a
Life Safety Code issue because Section
18/19.3.5.1 requires compliance with the
Standard for the Installation of Sprinkler
Systems (NFPA 13-1999), which requires
that there be an adequate water supply.
If the organization is unable to meet
the minimum requirements of the Life
Safety Code regarding this issue, its sprinkler system will be considered to be compromised, and the organization will need
to take additional action. For example,
one hospital experienced a lack of water
pressure following several construction
projects. If the organization had left this
situation unaddressed, it could have been
cited for noncompliance at Standard
LS.02.01.35, EP 14. Fortunately, repiping the supply and replacing several 90°
turns with 45° turns reduced piping
restrictions and allowed the system to
meet minimum building requirements.
“No Smoking” signage and
ashtrays (LS.02.01.70, EP 4)
One of the topics that falls within
LS.02.01.70, EP 4, relates to Nosmoking signage. The Life Safety Code
requires that no smoking signs be prominently displayed at all major entrances
and supported by policy. (See
EC.02.01.03 for prohibition of smoking
except in specific circumstances.) If the
signs are not prominently displayed at
major entrances, then no-smoking signage must be used in any room, ward, or
compartment where flammable liquids,
combustible gases, or oxygen is used or
stored, and in any other hazardous location (see 18/19.7.4). A risk of noncompliance occurs when no smoking signs
are removed from major entrances and
oxygen use areas do not have
appropriate signage.
(Note that the international symbol for NO
SMOKING, right, may
be used as alternative signage.)
Another issue scored at EP 4 deals
with ashtrays. The Life Safety Code
requires that all areas where smoking is
allowed must have noncombustible ashtrays and must also have metal containers
(continued on page 9)
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OSHA & Worker Safety
Protection Partnership
How health care organizations can better secure the safety of
workers and patients alike
Note: This is Part 2 of a two-part series
that explores the significance of mutual
patient and worker safety and ways both
groups can be better protected.
A
confused elderly patient attempts
to leave her hospital bed in the
middle of the night to use the
bathroom. A nursing assistant rushes to
help her return to bed, but the patient slips
from her grip and strikes the floor and the
bed frame. The patient sustains bruising,
and her stay is lengthened, while the
nursing assistant experiences back pain and
misses three days of work.
Scenes like this hypothetical one play
out in health care settings with alarming
frequency. Consider that one out of three
hospital patients experiences adverse
events during hospitalization.1 And more
workers in the health care and social
assistance industry sector are injured (5.2
out of 100 workers in 2010, on average)
than in any other private industry (an
average of 3.5 out of 100 workers).2
The example also demonstrates that
the safety of employees and patients in
health care organizations (HCOs) is
inseparably linked. The Joint Commission’s recent monograph, Improving
Patient and Worker Safety: Opportunities
for Synergy, Collaboration and Innovation,
is devoted to this concept.3 Understanding this synergy, the value of mutual
safety, and how to better protect both
groups (issues that are explored in Part 1
of this series, published last month) is
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vital. Equally important, however, are
learning how to increase your organization’s reliability, stressing incident reporting and feedback, and creating an
effective safety climate.
High-reliability organizations
Working to improve both worker and
patient safety is essential to becoming a
high-reliability organization (HRO).
HROs have been described as “systems
operating in hazardous conditions that
have fewer than their fair share of adverse
events.”4
“[HROs] understand that humans
fail. Everybody makes mistakes; it’s part
of human nature. And it will happen
when you least want it to,” says Rosemary Sokas, MD, MOH, professor and
chair, Department of Human Science,
Georgetown University School of Nursing and Health Studies, Washington,
DC. “So you plan for that and create
backup systems to catch failures before
they can cause a bad outcome. In an
[HRO], there’s an obsession ahead of
time with what can go wrong and how
you can prevent it.”
To help with prevention of adverse
events, HROs should respect the experience of workers and train them appropriately. “That way, when things do go
wrong, you have a trained workforce that
knows how to adapt,” says Sokas. “You
should also promote teamwork and
communication across hierarchies, and
include frontline workers as safety
monitors who can really tell you if you’re
‘walking the walk.’”
The Joint Commission strongly supports health care organizations working
toward becoming HROs. In fact, The
Joint Commission’s High Reliability
Resource Center webpage is devoted to
tools, tips, and articles to help organizations in this quest. See the website at
jointcommission.org/highreliability.aspx.
Essential changes
HCOs must make the following three
interdependent, essential changes to
become highly reliable:
1. Leadership must commit to the goal
of high reliability.
2. An organizational culture that supports high reliability must be fully
implemented.
3. The tools of robust process improvement must be adopted.5
For example, per Joint Commission
Environment of Care (EC) standards, an
HCO aiming to become an HRO should
carefully evaluate new types of medical
equipment before initial use and maintain a written inventory of all medical
equipment. (See EC.02.04.01 and
EC.02.04.03.) An HCO should ensure
that it has a reliable emergency electrical
power source for alarm systems, exit
routes, emergency communication systems, essential medical equipment, and
clinical care areas. (See EC.02.05.03.)
(continued on page 8)
EC NEWS
June 2013 7
Protection Partnership
(continued from page 7)
Safety Culture Characteristics
Effective reporting systems
A safe culture and workplace is also
highly dependent on a proactive surveillance system to identify hazards and
risks, evaluate them, prevent future
occurrences, and mitigate the effects of
breakthrough occurrences. Managers
should encourage employees and other
stakeholders to report hazards. Hazard
identification will be more effective with
an easy-to-use reporting system that
rewards those who choose to file reports.
Essentially, workers want to do a good
job, “but they need to have the tools,
information, and training to do so. They
also want to be appreciated for what they
do,” says Sokas. “Encouraging incident
reporting and providing healthy feedback
lets them know they’re appreciated and
builds trust.”
“Systems for (incident) reporting and
investigation of individual events as well
as near misses or close calls can generate
useful information to identify opportunities for improvement in local systems and
processes,” says Barbara Braun, PhD,
project director, Department of Health
Services Research, Division of Healthcare
Quality Evaluation for The Joint
Commission.
Without an effective feedback system
in place, workers either can’t report a
problem or don’t bother because they
don’t expect anything to be done about
it, Sokas says.
Safety culture club
One of the most significant ways to
become an HRO and, thus, better protect both patients and workers is to promote an effective culture of safety.
According to the Joint Commission
monograph, a safety culture is a subset of
an organization’s overall climate that does
the following3:
• Focuses on people’s perceptions about
8
EC NEWS
July 2013
According to findings of a recent survey by the Agency for Healthcare Research and
Quality (AHRQ),6 most health care organizations (HCOs) that could be considered
to have a culture of safety display four areas of strength.
Areas of strength
1. Teamwork within units—staff support each other, treat each other with respect,
and work together as a team.
2. Supervisors/managers consider staff suggestions for improving patient safety,
praise staff for following patient safety procedures, and do not overlook patient
safety problems.
3. Organizational learning—mistakes have led to positive changes, and changes
are evaluated for effectiveness.
4. Hospital management provides a work climate that promotes patient safety and
shows that patient safety is a top priority.
However, for many HCOs, flaws still remain, specifically in three areas for
improvement.
Areas for improvement
1. Workers should feel that their mistakes and event reports are not held against
them and that mistakes are not kept in their personnel file.
2. Important patient care information should be transferred across hospital units
and during shift changes.
3. There should be enough staff to handle the workload, and work hours should be
appropriate to provide the best care for patients.
the degree to which the organization
values safety for workers, patients,
and/or the environment
• Commits resources to safety-related
initiatives and equipment
• Promotes safe behaviors
A safety culture can serve as a leading
indicator of safety performance, as
opposed to error and injury rates, which
are lagging indicators of performance.
“A culture of safety has to start from
the top and be consistent day after day.
There has to be enough trust and the
idea that this is a culture where workers
can be respected, where they can be free
to admit mistakes without being afraid
they’ll get in trouble,” Sokas says. “It’s
hard to establish that level of respect and
trust, and it’s easy to break it if people
wind up being punished when they made
a mistake but intended to do well.”
An inadequate safety culture and poor
working conditions are linked to unfa-
vorable outcomes for workers, which are
associated with poorer patient outcomes,
per the Joint Commission monograph.3
Thus, HROs should emphasize both
worker and patient safety, which are
inseparably integrated, and identify their
safety culture strengths and weaknesses
(see “Safety Culture Characteristics,”
above).
HCOs can improve their safety culture in many ways. For example, they
can train frontline and security staff in
assault and violence prevention and management. This training can benefit
patients by leading to fewer injuries and
less use of restraint. Such training can
help workers by reducing anxiety and
promoting teamwork. HCOs can install
effective locks, lights, and video surveillance equipment in and around the facility, which can allay patient and staff fears
of violence. HCOs can also enforce better infection prevention programs by
www.jcrinc.com
having workers receive regular immunizations, follow recommended hygiene
practices, and wear personal protective
equipment (PPE)—resulting in
decreased transmission of pathogens
from workers to patients and patients to
patients.
Setting a good example
Although it’s important to train workers
properly and expect them to follow
established procedures designed to stress
safety, effective modeling from the top
down is necessary.
“As with any other business improvement initiative, a proactive approach to
safety and health starts with management
leadership and visibility,” says Patricia
Bray, MD, MPH, medical officer for the
Office of Occupational Medicine,
Occupational Safety and Health
Administration (OSHA). “It is essential
for management to lead by example and
to provide necessary resources to maintain a safe environment and to encourage
safe behaviors.”
Ensuring Full Compliance with the Life
Safety Code®
(continued from page 6)
with self-closing cover devices into which
ashtrays can be emptied. Surveyors have
noticed that in some instances, metal
containers used for emptying ashtrays fail
to have self-closing cover devices. They
are therefore cited as being noncompliant
(see 18/19.7.4).
Bedding, curtains, and other
furnishings (LS.02.01.70, EP 4)
Another topic that falls within
LS.02.01.70, EP 4, relates to curtains.
The Life Safety Code requires that all
draperies, curtains, and other loosely
hanging fabrics serving as furnishings in
health care occupancies meet NFPA 1012000 10.3.1, which requires flame resistwww.jcrinc.com
Bray says managers can promote an
effective safety culture in several ways—
by wearing PPE, asking workers during
walk-arounds if they have any safety concerns, responding promptly when issues
are raised, and investigating any incidents or near misses involving patients,
workers, or visitors.
Bray also encourages health care
organizations to enroll in OSHA’s Voluntary Protection Program (VPP; see http://
osha.gov/dcsp/vpp for details). VPP facilities have demonstrated a high degree of
effectiveness in reducing injuries and illnesses, and VPP participation can also
lead to lower employee turnover,
increased productivity, and cost savings.
3.
4.
5.
6.
May 14, 2013. http://www.osha.gov/pls/oshaweb
/owadisp.show_document?p_table=NEWS
_RELEASES&p_id=20883.
The Joint Commission. Improving Patient and
Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace, IL:
The Joint Commission; 2012. Accessed May 14,
2013. http://www.jointcommission.org
/improving_Patient_Worker_Safety/.
Reason J. Human error. Models and management. BMJ. 2000 March 18; 320(7237):
768–770.
Chassin MR, Loeb JM. The ongoing quality
improvement journey: Next stop, high reliability.
Health Aff (Millwood). 2011;30(4):559–568.
Agency for Healthcare Research and Quality.
Hospital Survey on Patient Safety Culture: 2012
User Comparative Database Report. Accessed
May 14, 2013. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture
/hospital/2012/hospsurv1223.pdf.
EC
References
1. Classen D, et al. Global trigger tool shows that
adverse events in hospitals may be 10 times
greater than previously measured. Health Aff
(Millwood). 2011;30(4):581–589.
2. US Department of Labor. Statement from Secretary of Labor Hilda L. Solis on reported decline
in workplace injuries and illnesses. OSHA News
Release: 11-1547-NAT, Oct 20, 2011. Accessed
ance ratings demonstrated by testing in
accordance with NFPA 701, Standard
Methods of Fire Tests for Flame Propagation of Textiles and Films. The Joint
Commission also recognizes CAL 133,
Flammability Test Procedure for Seating
Furniture for Use in Public Occupancies,
and CAL 117, Requirements, Test Procedure and Apparatus for Testing the Flame
Retardance of Resilient Filling Materials
Used in Upholstered Furniture.
Cubicle curtains are included in this
section and are also discussed in
18/19.3.5.5, with a reference to NFPA
13-1999, Standard for the Installation of
Sprinkler Systems. NFPA 13 requires that
hanging cubical curtains not compromise
the 18-inch clear space below the sprinkler. Noncompliance with this requirement is scored at LS.02.01.35, EP 6.
This article was developed through the
cooperative efforts of the OSHA/Joint
Commission Resources Alliance.
Note that organizations often address
this requirement by designing a cubical
curtain to have a mesh top (1⁄2-inch diagonal or a 70% open weave) that extends
18 inches below the sprinkler deflector.
This solution is compliant with
LS.02.01.35, EP 6.
Further concerns
This column offers a brief discussion of
some compliance issues that surveyors
are seeing, but it does not represent an
exhaustive list. Organizations must keep
in mind that The Joint Commission
requires full and complete compliance
with the NFPA’s Life Safety Code. Taking
time to review that document along with
the LS Chapter may be beneficial in furthering your organization’s compliance
efforts. EC
EC NEWS
July 2013 9
Revisions to Applicability of EC Requirements
for Freestanding Ambulatory Infusion and
Rehabilitation Technology Settings in the
Home Care Program
T
he Joint Commission is committed to an ongoing process of
gathering customer and stakeholder feedback on current standards. It
uses this feedback to assess standards and
clarify, restructure, or delete requirements based on their value and applicability to accredited organizations.
Recently The Joint Commission
received comments and questions from
customers concerning several Environment of Care (EC) standards and
elements of performance (EPs) as they
relate to two home care settings: freestanding ambulatory infusion (FSAI) and
rehabilitation technology (RT). FSAI
organizations provide the dispensing and
administration of drug therapy by infusion or inhalation (and other related
services) to ambulatory patients under
the supervision of a licensed health care
professional (for example, a nurse). These
services are provided in a room or an
office that is neither an extension of a
physician office or hospital nor part of a
larger ambulatory home care organization. RT is a component of home medical equipment (HME) services that
enhances the lifestyle of physically challenged individuals through the sale and
rental of custom medical equipment
(such as mobility systems and adaptive
equipment) and ongoing evaluation by
trained rehabilitation technologists. RT
services may be provided in the patient’s
home, rehabilitation clinics, or the home
care organization’s facility/office.
Most FSAI and RT services are provided in office settings that are classified
as business occupancies according to
National Fire Protection Association
10
EC NEWS
July 2013
Editorial Revisions to Standard EC.02.03.05 for Home Care
The following note was added to the standard:
Note 2: The references to the National Fire Protection Association (NFPA)
guidelines noted at the elements of performance are for information only.
EPs 3 and 4 were made “not applicable” for these settings. In place of these EPs,
the following EP was created for FSAI and RT settings:
C 26.  Every 12 months, the organization tests the following:
■ Manual pull stations
■ Smoke detectors
■ Visual and audible fire alarms
The completion date of these tests is documented.
Note: For additional information on performing tests, see NFPA 72, 1999 edition
(Table 7-3.2).
Changed “For additional guidance” to “For additional information” wherever this
phrase appears in the Notes to the EPs.
(NFPA) guidelines. Business occupancy
health care settings include facilities in
which no one stays overnight and, given
the nature of their treatment, three or
fewer individuals are rendered incapable
of self-preservation at any time. Because
most FSAI and RT services are provided
in business occupancy settings, they are
not required to follow the same set of
NFPA fire safety guidelines required for
other inpatient and outpatient health
care settings.
In response to customer feedback
requesting a review of the applicability of
EC standards to these two settings, The
Joint Commission convened an internal
group of home care representatives (staff
and surveyors) and Life Safety Code®*
engineers in the fall of 2012. Specific
* Life Safety Code® is a registered trademark of the
National Fire Protection Association, Quincy, MA.
Editorial Revisions to
Standard EC.02.05.03 for
Home Care
Changed “For guidance” to “For
information” in the Note to EP 1.
Removed the reference to the Life
Safety Code from EPs 1 and 2.
issues raised by customers focused on
standards that require these organizations
to maintain the following:
• Fire safety building features
(EC.02.03.05)
• Utility systems (EC.02.05.01)
• Emergency communication systems
(EC.02.05.03)
• Testing of utility systems before initial
use (EC.02.05.05)
• Testing of emergency power systems
(EC.02.05.07)
(continued on page 11)
www.jcrinc.com
In addition to the internal group’s
review of Joint Commission standards
and related NFPA fire safety guidelines
for business occupancy settings, the
research included a review of internal
data collected from various customers.
The information gathered was then presented to The Joint Commission’s Home
Care Advisory Group for its review and
recommendations.
The Joint Commission used this
research as well as feedback from the
Home Care Advisory Group to make
Test your
STANDARDS
several editorial revisions and remove
applicability for the following EPs determined to be irrelevant to or inappropriate for FSAI and RT settings (though
they remain applicable to other home
care settings):
• EC.02.03.05, EPs 1–14, and 17–20
• EC.02.05.01, EPs 3–4
• EC.02.05.03, EP 3
• EC.02.05.05, EP 1
• EC.02.05.07, EPs 3–6
The editorial revisions to the EC standards for all home care settings are sum-
IQ
The Answers
• Evidence of the practitioner’s demonstrated ability to continue to provide
adequate care, treatment, and services
• Evidence of the hospital’s attempt to perform primary source verification as
soon as possible
If primary source verification of licensure cannot be completed within 72
hours, the standards require that it be performed as soon as possible.
STANDARDS REFERENCE: EM.02.02.13, EPs 7–9
Here are the answers to the questions on page 2. How did you do?
1.
D, At a frequency determined by law and regulation. Laboratories, along
with ambulatory care organizations, hospitals, critical access hospitals, and
office-based surgeries, must monitor levels of hazardous gases and vapors to
verify that they are within safe range. Law and regulation should dictate the
frequency of this effort as well as acceptable ranges. Organizations may want
to consult the websites of the Occupational Safety and Health Administration
(OSHA) and the National Institute for Occupational Safety and Health
(NIOSH) for guidance in establishing safe ranges.
STANDARDS REFERENCE: EC.02.02.01, EP 10
2.
False. Although it is wise to have doors in the means of egress (the path for
safely leaving an area during a fire) open in the direction of egress, this is
required only for organizations whose occupancy is 50 or more. Having doors
swing in the direction of egress ensures that people can exit an area quickly
and creates a safe path without restrictions. If this requirement were not in
place, egress doors in larger organizations could restrict movement during an
emergency. For example, if a press of people is trying to get through a door
quickly, it could be problematic if they have to stop and open the door toward
them prior to leaving. (For full text and any exceptions to this requirement,
refer to NFPA 101-2000: 7.2.1.4.2.)
STANDARDS REFERENCE: LS.02.01.20, EP 2
3.
C, 72 hours. A hospital has 72 hours in which to decide whether to continue a
volunteer licensed independent practitioner’s granted disaster privileges. To
help with this determination, organizations must conduct primary source
verification of licensure as soon as the immediate emergency situation is
under control. If such verification cannot be completed within 72 hours due to
extraordinary circumstances, the hospital must document all of the following:
• Reason(s) primary source verification could not be performed within 72
hours of the practitioner’s arrival
www.jcrinc.com
marized in the two boxes on page 10. All
changes are effective July 1, 2013, and
appear in the 2013 Update 1 to the
Comprehensive Accreditation Manual for
Home Care as well as the spring 2013 Edition® update.
If you have any questions about the
home care EC standards revisions or
applicability changes, contact Kathy
Clark, MSN, RN, associate project director and home care specialist, Department
of Standards and Survey Methods, at
[email protected]. EC
4.
False. The need for organizations to map the distribution of their utility
systems is not limited to hospitals. Standard EC.02.05.01, EP 7, requires all
settings, with the exception of home care organizations, to engage in this
activity. A utility map should show the operations of all an organization’s
various utility systems, including water; medical gas; heating, cooling, and
ventilating; and electrical systems. These drawings should show where the
utilities enter the building and how they are distributed throughout the facility.
They should also show where the end points of use are and where emergency
interventions can be performed, if necessary. It’s important for organizations
not only to have such maps but to understand and use them as a reference
during partial or complete emergency shutdowns. Note that for office-based
surgery, only those practices that use electrical life support equipment, provide
patients with assisted mechanical ventilation, or have blood, bone, and tissue
storage units are required to have utility distribution maps.
STANDARDS REFERENCE: EC.02.05.01, EP 7
5.
D, Every 12 months. Ambulatory care organizations that have visual and
audible fire alarms must test those alarms every 12 months and document
test completion. Annual fire alarm testing is also required for all other settings
except laboratories, provided that the organization has visual and audible fire
alarms in place. To determine the appropriate method for testing,
organizations should consult NFPA 72, 1999 edition (Table 7-3.2).
STANDARDS REFERENCE: EC.02.03.05, EP 4
EC NEWS
July 2013 11
Volume 16, Issue 7, July 2013
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EC News
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